Patient said that she has been needing to go" to the bathroom a lot" and that ‘it burns and hurts" when she urinates and that it has been going on for 2 days now
WPMCTICE EXERCISE 1. Please organize these notes using the SOAP format— Please make sure you note the Chief Complaint. 1ll’v’rite S, D. A. or P in front ofthe letters. Patient said that she has been needing to go" to the bathroom a lot" and that ‘it burns and hurts" when she urinates and that it has been going on for 2 days now. She has had chills and fever Patient is 21—years old T: QQBF Patient stated that she is sexually active P: 86 R18 BP: 12032 w; 5’?” w: 142Ib Patient said that she has had chills and fever General appearance: patient appears uncomfortable. Heart rate and rhythm are regular. Skin is warm and moist acute cystitis Upon receiving the results of a complete urinalysis that revealed red blood cells. white blood cells, and bacteria. the patient was placed on Bactrim DS 160mgt800mg {trimethoprim—sulfamethoxazole} 1 Tab PO bid x 14 days and Pyridium (phenazopyridine HCL) 200mg 1 Tab PD up: 2 days Schedule a follow—up @ for one week Patient denies N 8. ‘v’ and Hit of previous UTI. PpaFrLoaLowonp 9 LL 2. Please enter a w with date, time and note the following: In the aftemoon, you go into a Patient’s @ and you notice that the patient has not touched her lunch. she is lethargic and she asks for your help to get off the bed and go to the bathroom. Her blood pressure is g and she feels dizzy. You take vital signs. Patient tells you that she does not have an appetite and that she feels dizzy. Patient took 2 tablets of 500 mg Ibuprofen for pain at 10.00am Date Time 3. Correct the progress note you just wrote as it should read 2 tablets 01250 mg Ibuprofen for pain at 10:0[Jam
l"HiAFtTII’hlG AND SOAP NOTES — PRACTICE EXERCISE In which area oftthte — S. 0. A, or P. would each of the following pieces ofintormation best fit’?I Patient said that she has aching all over: and is feeling feverish Patient stated that she is 21—years old T: tflOF P: 36 FMS BP: 1201?: 5.11 5’3"” M1 135lb Patient stated that she has been coughing as well Lungs are clear General appearance: patient appears tired and achy Heart rate and rhythm are regular. Skin is warm and moist Flu Patient stated that she has no pain in her chest No sign of bacterial infection in the lungs 3th patient home and recommended plenty of rest and fluid. nuc:3?;¢’?’f-‘:rur~ma_num_w_—s What is the Chief Complaint? [wn’te letter (3] and statement [5}] 1. The patient stated that she has a stomach-che and that she did not sleep well last night, had anxiety . The patient blood pressure is 122m The health care worker [you] gave the patient 1 tablets of 400mg Zantac by mouth The health care worker [you] saw the patient on April 4L". E at 2:00pm The health care worker [you] will advise the psychiatrist about the patient’s anxiety and lack of sleep. “FF-4N Please make sure you observe the characteristics of good medical documentation when you write these statements in one progress note. Remember this is a narrative progress note with one entry only. DATE TIME
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